Surgical Options

What are the Different Types of Bariatric Surgery?

Each of the different operations to treat morbid obesity has advantages and disadvantages. No single operation is right for everyone. When you meet with our surgical weight loss team, we will help you decide which operation is best for you based on your individual history. Pre- and postoperative diets are the same no matter what surgery you undergo.

Common operations include:

• Robotic-assisted Laparoscopic Roux-en-Y Gastric Bypass

  The Robotic-assisted Laparoscopic Roux-en-Y (pronounced “roo-on-why”) gastric bypass (RYGB) has been around for more than 30 years and provides excellent weight loss.

  A surgical stapler is used to separate the upper portion of the stomach from the lower portion. The upper portion, only 1 to 2 tablespoons in size, is referred to as the “pouch.” This pouch is then connected to a limb of small intestine called the ”Roux limb.” Food enters the pouch, and then passes through a limb of the small bowel. The bypassed limb (or biliopancreatic) contains digestive juices which mixes the food with the digestive juices in the “common channel,” the part of small intestine downstream from the Y connection.

  The gastric bypass promotes weight loss by both restriction and malabsorption mechanisms:

  • Restriction: The stomach pouch is small and determined by physician preference. The pouch fills up very quickly after you eat only a small amount of food, providing a sensation of fullness. Thus, the small pouch places a physical restriction on the amount of food you are able to eat (or want to eat) at a sitting.
  • Malabsorption: Because sections of the stomach and intestines are bypassed, you will absorb fewer nutrients from the food you eat. You will need vitamin and mineral supplements after the operation for the rest of your life.

  Advantages

  • Experience: RYGB has been around the longest of any bariatric operation.
  • Faster results: Weight loss may be more rapid than with other procedures, when dietary guidelines are followed.
  • No foreign body: RYGB leaves no devices behind in your abdomen.
  • Follow-up: Fewer post-operative visits are required in comparison to the Gastric Band.

  Disadvantages

  • Postoperative healing: Surgery is more extensive, with rerouting of digestive organs. Patients may have more nausea which may take longer to resolve.
  • Hospitalization: Patients usually spend 2-3 days in the hospital after surgery. Additional issues of dehydration or electrolyte disturbance may occur if the patient does not follow the recommended diet and vitamin replacement.
  • Permanence: This procedure is not reversible.
• Robotic-assisted Laparoscopic Sleeve Gastrectomy

  Now the most common bariatric procedure performed in the United States, it is also one of the safest.
  
  The Robotic-assisted Laparoscopic Sleeve Gastrectomy is an operation in which 80% of the left side of the stomach is surgically removed. This results in a new stomach, roughly the size and shape of a banana. Since this operation does not involve any rerouting or reconnecting of the intestines, it is an operation with less anatomic rearrangement than gastric bypass. Unlike adjustable gastric banding, the sleeve gastrectomy does not require implanting an artificial device inside the abdomen.
  
  For certain patients, in particular those with a BMI over 70, the sleeve gastrectomy may be the first part of a two-stage operation. In the staged approach, the operation is broken down into two separate operations. In the first stage, a sleeve gastrectomy is performed, with patients potentially losing 80 to 100 pounds or more, making the second part of the operation substantially safer. If weight loss is initially successful, the patient may not need the second operation.
  
  Advantages

  • Permanent portion control
  • No anatomic rearrangement: A lack of bypassing a portion of bowel decreases the chance of vitamin difficiency.
  • No foreign body: No device left behind in your abdomen.
  • Follow-up: Fewer post-operative visits are required in comparison to gastric banding.
  • Safety: This operation is less complex than gastric bypass with fewer anatomic changes and rearrangements. Weight loss after the first operation may make a second operation safer.

  Disadvantages

  • The lack of bypassing a portion of the bowel decreases the frequency of malabsorption issues. Some patients have a new onset of heartburn, usually for a short period of time postoperatively.
  • Staged operations: Patients may face the risks of surgery twice.
• Robotic-assisted Laparoscopic Adjustable Gastric Band

  The adjustable gastric band (AGB), a small device made of silicone rubber, is wrapped around the uppermost portion of the stomach. Gastric banding works by decreasing the functional size of the stomach, promoting weight loss by restriction. The AGB turns the stomach into an hourglass shape; the upper portion of the hourglass is called the stomach pouch. The stomach pouch is only 15 to 30 ml in size – 1 or 2 tablespoons.

  The band is adjustable, therefore about four to six weeks after surgery, you will return to the hospital for your initial band fill. The band is filled by injecting saline (salt water) through an access port located underneath the skin within your abdominal wall. If the restriction is too tight or too loose, you will come back in for an adjustment (adding or removing saline). This tool requires frequent visits for appropriate management and optimal weight loss.

  Advantages

  • Adjustability: Adjustments allow the amount of restriction to be tailored to achieve your personal goals.
  • Lower risk of leak: No cutting or stapling of the stomach is required.
  • No anatomic rearrangement: A lack of bypassing a portion of bowel decreases the chance of vitamin difficiency.
  • Reversibility: The LAGB can be deflated or removed. The other types of surgery make permanent anatomic changes.

  Disadvantages

  • Adjustability: Weight loss is entirely dependent the patient’s commitment to dietary change. No permanent portion control.
  • Gradual weight loss: Weight loss with the AGB is variable. Weight loss tends to be less and more gradual with the AGB than with sleeve gastrectomy or gastric bypass.
  • Foreign body: The AGB is a foreign body. When a foreign body is placed around the stomach, problems such as infection, slippage or erosion may occur.
  • More frequent follow-up: Everyone requires multiple band adjustments (at least 3 or 4 in the first several months). Some people require more adjustments. For some people, it may be difficult to find the perfect adjustment where the band is tight enough for good weight loss but not so tight that it causes nausea and vomiting.
  • Re-operations: The AGB is associated with the highest need for re-operation than sleeve gastrectomy or gastric bypass. Up to 20 percent of patients may need revisional surgery after initial band placement.
• Robotic-assisted Laparoscopic Revisional Bariatric

  Revisional Weight Loss Surgery is a surgical procedure that is performed on patients who have already undergone a form of bariatric surgery (e.g. VBG, gastric banding (LapBand®), Roux en Y Gastric Bypass, etc.), and have either had complications from their surgery (e.g. difficulty swallowing) or have not successfully achieved significant weight loss results from the initial surgery. Procedures are usually performed in a robotic-assisted laparoscopic fashion, though open surgery may be required if prior bariatric surgery has resulted in extensive scarring within the abdomen. There are several weight loss surgery options, some of which may limit later options for revisional weight loss surgery.
  Patient Criteria for Revisional Bariatric Surgery

  Patients should have a consultation with the bariatric surgeon in order to gather past medical and surgical information as well as to determine the cause of their difficulty and to evaluate the need for a revisional bariatric procedure. Ideally, patients will provide us, if possible, with the report of the original bariatric procedure. In addition, an Upper GI – Swallow Study and/or Upper Endoscopy may be ordered by our surgeons to com­plete the evaluation and to delineate the anatomy of the digestive tract.

  Our bariatric surgeon will need to determine if inadequate post-operative weight loss is due to a problem with the original surgery or the patient’s lack of necessary lifestyle changes. The doctor will want to discuss the options and what a patient should expect from a bariatric revision. As revisional surgery will be more complex and involve more risks than general bariatric surgery, the patient will be required to participate in dietary and psychological counseling and education prior to consideration of any revisional surgery.
  Results with a Bariatric Revision

  In general, revisional bariatric surgery is successful in resolving the patient’s associated problems and promoting further weight loss. Weight loss following a revision is often not as dramatic as the initial bariatric proce­dure, but it can be substantial over time with appropriate adherence to lifestyle changes.

Life After Surgery

What are the Results of Bariatric Surgery?

There is no way to predict exactly what will happen for any individual. The outcome of each surgery depends on many factors, including the patient’s preoperative BMI and their health at the time of surgery. The most important factor is commitment. Patients who follow dietary and exercise guidelines are much more likely to succeed. Those who continue to overeat after surgery will not be successful. The most important factors to predict long term success is a consistent activity regimen, as well as diligent dietary habits.

Follow-up studies have shown that 60 to 80 percent of those undergoing bariatric surgery are successful-meaning they lose at least half of their excess weight and keep it off for at least five years.

What is the Postoperative Diet?

Our dedicated dietitians will provide detailed information and counseling on proper and preoperative and postoperative dietary guidelines. Yes, you will always be able to eat regular food. Just prior to and immediately following surgery, your diet will be stages of liquid to solid in order to allow adequate healing. Your long term diet should be high protein, low fat and well balanced. You will be expected to take a daily multivitamin supplement as everyone should. Meals will remain small, portion control is one of the key elements to maintaining your weight loss once your goal is reached.

What About Exercise?

Surgery is not a substitute for exercise. An active lifestyle is essential for long term success after weight loss surgery. It helps to burn calories, increase metabolism, and stabilize blood sugar. To begin, simple changes to adopt are using stairs instead of taking the elevator, parking further away from entrances, and consider walking instead of driving. Walking and water based activities are a great way to begin to establish an active lifestyle. Eventually patients will establish a regular habit of daily activity, ideally prior to surgery